Reporting Requirements

40.4.1 - Reporting Requirements (Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) 42 CFR §422.157(c) When an AO is approved by CMS for deeming authority, the AO agrees to certain ongoing activities, including: 1. Providing to CMS, in written form and on a monthly basis, all of the following: a. Copies of all accreditation surveys, together with any survey-related information that CMS may require (including CAPs and summaries of unmet CMS requirements); b. Notice of all accreditation decisions; c. Notice of all complaints related to deemed MAOs; d. Information about any MAO against which the AO has taken remedial or adverse action, including revocation, withdrawal or revision of the MAO’s accreditation within 30 days of taking the action; and e. Notice of any proposed changes to its accreditation standards or requirements or survey process. If an AO implements any changes before or without CMS approval, CMS may withdraw its approval. 2. If an AO finds a deficiency in an MAO that poses an immediate jeopardy to the organization’s enrollees or to the general public, it must give CMS written notice of the deficiency within three days of identifying the deficiency. 3. When CMS gives notice that it is withdrawing its approval for deeming authority, the AO must notify all its accredited MAOs within 10 days. 4. AOs must provide, on an annual basis, summary data to be specified by CMS that relate to the past year’s accreditation activities and trends. 5. Within 30 days after CMS changes a Medicare MAO requirement, the AO must: a. Send a written acknowledgement of CMS’ notice of the change; b. Submit a new crosswalk reflecting the new requirement; and c. Send a written explanation of how it plans to alter, within a time frame that CMS will specify in the notice of change, its standards and review process to conform to CMS’ new requirement. 6. AOs must have a mechanism for publicly disclosing the results of an MAO’s accreditation survey. Accreditation surveys of MAOs performed by private AOs under section 1852(e)(4) of the Act may not be released to the public by CMS, except to the extent that such surveys relate to an enforcement action taken by the Secretary. AOs must, however, have methods to disclose the accreditation status of deemed MAOs.